Provider Demographics
NPI:1821492349
Name:KHONDAKER, SAL
Entity Type:Individual
Prefix:
First Name:SAL
Middle Name:
Last Name:KHONDAKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12509 DORSETT RD
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-3909
Mailing Address - Country:US
Mailing Address - Phone:314-434-4224
Mailing Address - Fax:314-424-6119
Practice Address - Street 1:12509 DORSETT RD
Practice Address - Street 2:
Practice Address - City:MARYLAND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63043-3909
Practice Address - Country:US
Practice Address - Phone:314-434-4224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-13
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013027422183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist